ACLS 2005 Update

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  • ACLS 2005What is new and why?Morbidity RoundsFeb 15, 2006Rob Hall MD, FRCPC

  • OverviewGoal = review major changes to CPR, ALS, electrical therapies, cardiac arrest, arrythmia algorithms, post resusc careBriefly review some Landmark papers.AEDs, ACS, CVA, toxicology and other special resusc situations not included

  • ACLS 2005 GuidelinesVISIT www.circulationha.orgCirculation 2005. Dec 13: 112(24): p3667-3813 and Supp 11: p 1-211.

  • Global CommentsBACK TO THE BASICSIncreased emphasis on CPRDecreased emphasis on drugsSIMPLERConsistent ratios for CPRLess algorithms (PEA/Asystole out)Tachycardia much simplerEVIDENCE BASEDNice to see Landmark papers incorporated.Recognition of importance of survival to discharge vs survival to admission

  • Circulation 2005;112:IV-19-34IV-CPR/BLS

  • Part 3/4: CPR/Adult BLSLay RescuersLay rescuers not taught artificial respirations or pulse checksLay rescuers taught to look for normal breathingLay rescuers not taught the jaw thrustAge definitionsNeonatal age applies to baby deliver up until they leave hospitalDifferent age cut offs for Lay rescuers8 year (Lay rescuer)adolescent to adult (HCP)

  • Part 3/4: CPR/Adult BLS VentilationsLess important than compressions (EARLY)Ventilate enough to make chest riseRate about 10 per minute after advanced airwayAVOID over - ventilation (decreased venous return, decreased cardiac output) AVOID rapid/forceful breathsAVOID interruption of compressions after advanced airway placed

    LOW AND SLOW ventilations

  • Part 3/4: CPR/Adult BLS CompressionsMore important than ventilation Rate about 100 compressions per minutePush hard enough to compress the chestAllow full recoil of chestAllow equal time for compression and recoilMINIMIZE interruptions in compressionsSynchronicityUnsynchronized ventilation/compression after advanced airway placedHARD AND FAST compressions

  • ED Interruptions in CompressionsTransfer to ED bedPulse checksPlacing patient on the monitor and defibrillatorRhythm checksVascular accessAirway managementDefibrillationDrug deliveryBedside ultrasoundABG drawPhysical examinationChangeover of compressorWe should minimize CPR interruptions

  • ACLS 2000After Advanced Airway Device Placed: 5 compressions to 1 ventilation (synchronized)

  • ACLS 2005After Advanced Airway Device Placed: 100 compression/min10 breaths per minute (unsynchronized)

  • ACLS 2005After Advanced Airway Device Placed: 100 compression/min10 breaths per minute (unsynchronized)

  • Circulation 2005;112:IV-19-34IV-Adult BLS Healthcare Provider Algorithm

  • Circulation 2005;112:IV-19-34IV-Electrical Therapies

  • Part 5: Electrical Therapy

  • Part 5: Electrical TherapyTruncatedExponentialRectilinearBiphasic = increased ROSC, no increase Survival to hospital discharge

  • Lifepak12 and 20 are both biphasic (truncated exponential)

  • Recommended Energy for DefibrillationLifepak 12 and 20Peds: 2 J/kg then 4 J/kg

  • Recommended Energy for Cardioversion for Lifepak 12/20

  • Timing of DefibrillationShock First vs CPR First?

  • Evidence for CPR before defibrillationCobb JAMA 1999Prospective observational trial, N=1117Pre-intervention = defibrillate ASAPPost-intervention = 90 sec CPR before defibSurvival to d/c Defib First CPR FirstPNNTOverall24% 30% .0416Response < 4min31% 32% .87Response > 4min17% 27% .007 10

  • Evidence for CPR before defibrillationWik JAMA 2003Randomized clinical trial, N=200Defibrillate ASAP vs CPR X 3 min before defibrillationSurvival to d/c Defib First CPR FirstPNNTOverall15% 22% .17Response < 5min29% 23% .61Response > 5min4% 22% .006 5.5

    A priori subgroup analysis

  • Evidence for CPR before defibrillationJacobs. Emerg Med Australasia. Feb 2005.Randomized clinical trial, N=256Defibrillate ASAP vs CPR X 90 sec before defibrillationSurvival to d/c Defib First CPR First OR 95%CIOverall5.1% 4.2% .81 (.3-2.6) Survival to d/c Defib First CPR First PResponse < 5min0% 12% .25Response > 5min4.9% 3.5% .74

    Post hoc subgroup analysis

  • Timing of DefibrillationACLS 2005 RecommendationCPR X 5 cycles of 30:2 (about 2 min) recommended for out-of-hospital VF arrestResponse time > 4-5 minutesUnwitnessed

  • Part 6: CPR Techniques and DevicesNon-traditional CPR and devices not universally recommendedRecognition of growing evidenceOptional for Health Care ProvidersActive Compression-Decompression CPRMechanic pistonsLoad Distributing Band CPR/Vest CPRResearchThoracic-Abdominal Compression-Decompression CPR

  • Circulation 2005;112:IV-19-34IV-ALS

  • Part 7.2: Management of Cardiac ArrestACLS Pulseless Algorithm 2005Vfib AlgorithmPEA AlgorithmAsystole Algorithm

  • Circulation 2005;112:IV-58-66IV-

  • Notes on VF and pulseless VTCPR 30:2 until defibrillator readyOne shock, not three150J (not 360J) Lifepak 12/20CPR X 2min right after shock (no rhythm check)Timing of intubation not specifiedTiming of vasopressor not specifiedEpinephrine 1mg or vasopressin 40IUTiming of antiarrythmic not specifiedAmiodarone 300mg or Lidocaine 1.5 mg/kg

    Circulation 2005;112:IV-58-66IV-

  • Amiodarone for Vfib/pulseless VTARREST TRIAL DBRCT, N=504Amio vs Placebo

    Survival PL Amio PAdmission 34% 44% .03Discharge 13.4% 13.2% NS

    ALIVE TRIALDBRCT, N = 347Amio vs Lidocaine

    Survival Lido Amio PAdmission 12% 23% .009Discharge 3.8% 6.8% NS

    Kudenchuk et. al. NEJM 1999. 341(12): p.871.Dorian et. al. NEJM 2002. 346(12): p.884.

  • Notes on pulseless PEA/asystoleFocus is on quality CPR and look for and treat reversible causesAtropineEpinephrine or VasopressinPACING is OUT!Three RCTS of prehospital transcutaneous pacing showed no benefit

    Circulation 2005;112:IV-58-66IV-

  • Why Vasopressin? Or why notLinder. Lancet 1997.N=40, out of hospital Vfib, vasopressin vs epiIncreased survival to admission not dischargeStiell. Lancet 2001.N=200, in-hospital Vfib/PEA/asystoleVasopressin vs epiNo difference in survival to discharge (power 0.8)

  • VasopressinWenzel. NEJM 2004. 350(2). P 105-113.DBRCT, N= 1186Out-of-hospital vfib/PEA/asystoleVasopressin 40IU vs Epinephrine 1mgSurvival all patients AVPEPIPAdmission36%31%.06Discharge10%10%.99Survival Asystole AVPEPIP NNTAdmission29%20%.02Discharge4.7%1.5%.04 31Problem = multiple subgroup analysis (29); suspected type I (alpha) error

  • Circulation 2005;112:IV-19-34IV-ALSTachy/Brady

  • Circulation 2005;112:IV-67-77IV-Bradycardia Algorithm

  • Bradycardia NotesNo major changesIncreased emphasis on early pacing for unstable patientsAtropine unlikely to work with infranodal blocks/escape rhythms2nd degree type II AVB3rd degree AVBWide QRS escape rhythm

  • Tachycardia AlgorithmGeneral CommentsMuch simplerCardiac function/Ejection Fraction decision branches removedLess drugs listed at each boxLess emphasis on trying to distinguish Vtach vs SVT + aberrancyNice approach ..

  • Circulation 2005;112:IV-67-77IV-ACLS Tachycardia Algorithm

  • Wide QRS Tachycardia

  • AFIB + WPWTijunelis. CJEM 2005. Vol7(4)p. 262-5.Literature review of Afib + WPW treated with amiodaroneNo controlled studies10 case reports7/10 developed Vfib or unstable VT

    AMIODARONE NOT SAFE for AFIB +WPW CARDIOVERSION is the treatment of choice

  • Part 7.5: PostresuscitationShould we induced hypothermia post cardiac arrest?

  • Induced Hypothermia:NEJM Feb 2002 --what is the evidence?Austrian Study RCT, N=136Witnessed VF/pulseless VTExcluded: Sats < 85%, hypotension > 30 min, coagulopathy, etc32-34 degrees X 24hrsResult cool warm NNTNeurofn 6mo 55% 39% 6Mortality 6mo 41% 55% 7

    Australian Study RCT, N=77Initial VF rhythm then comatoseExcluded: SBP

  • Part 7.5: PostresuscitationACLS 2005 Guideline for Induced HypothermiaRecommended for post Vfib arrest with ROSC but remains comatoseConsider for non-VF arrest

  • Circulation 2005;112:IV-19-34IV-What really matters?CPR/BLS/Defib

  • Why the emphasis on CPR and defibrillation?OPALS studyStiell. NEJM 2004. 351(7). P 647-656.BLS + Rapid DefibrillationN = 139112 months

    ALS care (ETT,iv,drugs)N = 424736 months

  • Why the emphasis on CPR and defibrillation?OPALS studyStiell. NEJM 2004. 351(7). P 647-656.BLS + Rapid DefibrillationSurvival to 11%15%p.001Admission

    Survival to5.0%5.1%p.83 Discharge

    ALS care (ETT,iv,drugs)

  • Why the emphasis on CPR and defibrillation?OPALS studyStiell. NEJM 2004. 351(7). P 647-656.Logistic Regression OR for survivalWitnessed arrest 4.4Bystander CPR3.7AED < 8min3.4

  • Take home pointsOne shock (not three) for VFLower energy with biphasic defibrillatorsLess emphasis on drugsMore emphasis on CPRCPR 30:2 ratioCPR before defibrillation for response times > 4 minutesQuality CPR with minimal interruptionsShould we call ourselves CPR-coaches?Why isnt CPR taught in high-school?